MEDICARE: CRISP & ASSOCIATES III, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	332B00000X	Durable Medical Equipment & Medical Supplies

General Provider Information

NPI Number	:	1275982373
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CRISP & ASSOCIATES III, LLC

Provider Business Mailing Address
First Line	:	1057 MAIN ST
Second Line	:	SUITE C
City	:	FOREST PARK
State	:	GA
Zip	:	30297-1482
Country	:	US
Telephone Number	:	404-362-6901
Fax Number	:	404-362-6904

Provider Business Practice Location Address
First Line	:	1057 MAIN ST
Second Line	:	SUITE C
City	:	FOREST PARK
State	:	GA
Zip	:	30297-1482
Country	:	US
Telephone Number	:	404-362-6901
Fax Number	:	404-362-6904

Authorized Official
Title or Position	:	OWNER
Name	:	MR. RAY WAYNE CRISP
Credential	:	RPH
Telephone Number	:	678-873-3192

Provider Enumeration Date	:	06/09/2016
Last Update Date	:	06/09/2016

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